|Year : 2015 | Volume
| Issue : 1 | Page : 125-132
Treatment of humeral shaft fractures by a single elastic stable intramedullary nail in children
Ahmad Abd El-Azeem Abosalim, Ahmad Fouad Shams El-Din, Hesham Mohammed El-Mowafy
Orthopedic Surgery Department, Faculty of Medicine, Menoufia University, Menoufia, Egypt
|Date of Submission||16-Aug-2014|
|Date of Acceptance||10-Nov-2014|
|Date of Web Publication||29-Apr-2015|
Ahmad Abd El-Azeem Abosalim
Elshamy Street, Menouf, Menoufia
Source of Support: None, Conflict of Interest: None
The aim of this study was to assess the effectiveness of intramedullary fixation of displaced humeral shaft fractures in skeletally immature children using a single elastic stable intramedullary nail.
Almost all pediatric humeral shaft fractures can be treated successfully using closed methods. Some patients, however, require internal fixation either because of an inability to maintain an adequate reduction, significant soft tissue injury, or concomitant fractures. In this study, the functional and radiological results of the management of humeral shaft fractures in children using a single retrograde elastic intramedullary nail will be evaluated.
Patients and methods
Twenty pediatric patients ranging in age from 6 to 16 years (mean age 10 years) were treated surgically using a retrograde single elastic intramedullary nail. Relative surgical indications included open fractures, inability to maintain an acceptable reduction, concomitant lower extremity fractures, and closed head injury. Two patients had associated radial nerve injury at presentation. Among the patients, 16 were males and four were females.
The patients were followed for a mean of 5.5 months, with a range from 4 to 6 months. Radiographically, all fractures healed in good alignment. Solid union occurred from 5 to 10 weeks, with a mean of 8 weeks. There were no intraoperative complications, including neurologic or vascular injury, and two patients developed superficial wound infections postoperatively.
It was found that single elastic intramedullary nail fixation with the aid of a functional arm brace is an adequate technique for the treatment of humeral shaft fractures in pediatric patients when surgical stabilization is indicated. This simple minimally invasive technique provides stable fixation, with minimal soft tissue stripping at the fracture site, and led to bone union in all the cases studied.
Level of evidence
Case series, level IV.
Keywords: Children, fracture, humerus, single elastic nail
|How to cite this article:|
Abosalim AA, El-Din AF, El-Mowafy HM. Treatment of humeral shaft fractures by a single elastic stable intramedullary nail in children. Menoufia Med J 2015;28:125-32
|How to cite this URL:|
Abosalim AA, El-Din AF, El-Mowafy HM. Treatment of humeral shaft fractures by a single elastic stable intramedullary nail in children. Menoufia Med J [serial online] 2015 [cited 2017 Jun 27];28:125-32. Available from: http://www.mmj.eg.net/text.asp?2015/28/1/125/155967
| Introduction|| |
Humeral shaft fractures in children [Figure 1] are very infrequent and only represent 2-5% of all pediatric fractures. They are predominantly encountered in children younger than 3 years or older than 12 years of age. Fractures of the humeral shaft usually result from a direct force such as a direct impact, road traffic accidents, and/or crush injuries. Indirect forces such as a fall on the elbow, or an outstretched hand, or even strong muscular contractions can cause these fractures. Pathologic fractures through unicameral bone cysts are also extremely common. The most frequent site of the fracture is between the middle and the distal thirds of the humerus [1,2]. The simplest classification of humeral shaft fractures is based on the location of the fracture site in the humeral diaphysis (proximal, middle, and distal), alignment of the fracture fragments, and the appearance of the fracture line . Radial nerve injury is the most common associated injury because of the close proximity of this nerve to the bone, especially in fractures of the middle third ,.
Humeral shaft fractures uniformly do well from a functional and cosmetic standpoint following nonoperative treatment using functional bracing, coaptation splinting, hanging arm casts, or sling immobilization. Newborns and infants have considerable remodeling capability, and deformities up to 45° remodel with growth. Older children also have a certain degree of remodeling potential; however, authors have recommended that the deformity should be reduced to 30° for proximal third, 20° for middle third, and 15° for distal third shaft fractures before proceeding with a nonoperative treatment ,.
Functional bracing that is frequently indicated for stable fractures with adequate alignment can most often be used to treat diaphyseal fractures of the humerus in children nonoperatively. Noncompliance and limited fracture stabilization are the main complications encountered with this type of treatment .
Children with traumatic humeral shaft fractures require operative treatment only infrequently, primarily in cases where surgical stabilization of humeral shaft fractures is required to assist with patient mobilization, wound care in open fractures, nursing care in children with closed head injuries, and to maintain adequate alignment in cases with failed conservative measures (loss of reduction in the follow-up period) and in cases where adequate alignment by primary closed reduction under the C-arm failed to be achieved especially unstable fractures ,,.
Although rigid plate osteosynthesis is the most widely accepted operative method, it has many disadvantages including extensive soft tissue surgical trauma, loss of the fracture hematoma, significant blood loss, increased operative time, prolonged hospitalization period, delayed rehabilitation, and the risk of intraoperative radial nerve injury. In addition, all the patients are subjected to another surgery for plate removal .
Several series of antegrade intramedullary stabilization of humeral shaft fractures (Rush rods and Ender nails) have been reported in the literature. Problems of shoulder impingement and adhesive capsulitis of the shoulder were a significant problem in these series because most of the nails were inserted in an antegrade manner through a small incision in the rotator cuff .
Since publication of outcomes of Spanish and Nancy groups in the early 1980s, elastic stable intramedullary nailing (ESIN) has become a well-accepted method of surgical treatment of diaphyseal fractures of long bones in children and adolescents .
In the literature, in all the published series, two elastic intramedullary nails were used for fixation of diaphyseal fractures of the humerus in children. In most of the studies, the nails were inserted in an antegrade manner, whereas in very few cases, a retrograde insertion was performed. Nevertheless, in all the published reports, two nails were inserted.
Chee et al.  reported in their study that they treated 12 cases of severely displaced proximal humerus fractures using a single retrograde intramedullary elastic nail. They stated that the use of a single nail instead of two nails proved to be adequate in the treatment of severely displaced proximal humerus fractures.
Garg et al.  treated 21 children with displaced and unstable diaphyseal forearm fractures using intramedullary elastic nails, one for each bone, and reported that ESIN is an attractive treatment option for displaced and unstable diaphyseal forearm fractures in children.
The biomechanical properties of ESIN depend on the three-point support that leads to intramedullary stability with neutralization of the shearing forces. The only remaining forces are the axial compression forces or axial traction forces, which promote healing and external callus formation .
However, achieving a well-balanced construct is slightly more complex as.
Significant contouring is necessary to provide the nail with an adequate elastic restoring force when subjected to angulation forces. The angle of curvature must be greater than the actual curvature of the nail in the medullary canal. Three-point contact with the bone is standard: the preferred anchoring site is the metaphysis opposite the entry hole, where dense cancellous bone provides the best stability in all three planes. The entry site always has less axial and rotatory stability. The main technical difficulty lies in the accurate positioning of the apex of the curve at the fracture site where the spread should be greatest .
A question was raised: would a single retrograde intramedullary elastic nail be sufficient for stabilization of diaphyseal fractures of the humerus in children?
In this study, the final functional and radiological results of management of such fractures in children using a single elastic intramedullary nail inserted in a retrograde manner will be presented.
| Patients and methods|| |
Twenty patients with humeral shaft fractures were included in this study. The patients were admitted to the orthopedic department, Menoufia University Hospital, during the period from February 2013 to February 2014, with a follow-up period of 4-6 months.
The approval of the medical ethic committee of Menoufia University and written consent were obtained from the parents. All the patients were treated using the same technique of retrograde single elastic intramedullary nailing.
Criteria of inclusion
The inclusion criteria were as follows: humeral shaft fractures of nonpathologic origin, closed fracture, first-degree or clean second-degree open fractures associated with lower extremity fractures to allow early mobility or in polytraumatized patients associated with other injuries (e.g. closed head injury) to facilitate nursing care or to achieve adequate alignment in cases with failed conservative measures (loss of reduction in the follow-up period) and in cases where adequate alignment by primary closed reduction under the C-arm failed to be achieved, especially unstable fractures. The age of the patients ranged from 6 to 16 years.
Criteria of exclusion
Patients with contaminated second-degree and third-degree open fractures and pathological fractures were excluded.
The fractures were classified according to the AO pediatric comprehensive classification of long bone fractures. The overall structure of the classification system is based on fracture location and morphology [Figure 2]. The fracture location comprises the different long bones and their respective segments and subsegments. The morphology of the fracture is documented by a specific child code that stands for the fracture pattern, a severity code, and an additional code that is used in certain types of displaced supracondylar humeral, displaced radial head and neck, and femoral neck fractures. Child codes within segment 2 (diaphyseal fractures) include bowing fractures (D/1), greenstick fractures (D/2), toddler fractures (D/3), complete transverse fractures (angle≤30° - D/4), and complete oblique/spiral fractures (angle>30° - D/5) .
|Figure 2: AO comprehensive classification of pediatric humeral shaft fractures.|
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Of the studied patients, 12 had a transverse fracture line (<30°, AO fracture type 12-D/4) and eight had an oblique or spiral fracture line (>30°, AO fracture type 12-D/5). There were 16 males and four females, 11 with right arm fractures and nine with left arm fractures. The mean age of the patients was 10.5 years at the time of surgery, with a range from 6 to 16 years. Radial nerve palsy was recorded in two cases before the index surgery. Seven fractures were caused by falling from height, six fractures were caused by direct trauma to the arm, four fractures were caused by pedestrian traffic accidents, and three fractures were caused by a twisting injury to the arm. Associated injuries included two children with lower extremity fractures, two children with closed head injury, and one child with abdominal organ injury.
A single prophylactic antibiotic was administered 2 h before the index surgery in the form of a third-generation cephalosporin injection, and the dose was adjusted according to the age and weight of the patient. General anesthesia was administered to all the affected individuals in the supine position. An orthopedic radiolucent table was used in all the cases to allow for the use of radiographic control (C-arm). A 5-10 mm skin incision was made over the lateral distal end of the humerus just overlying the lateral supracondylar region just above the level of the lateral humeral epicondyle. The point of insertion was about 2 cm above the growth plate. An oblique hole was made with a drill bit or an awl at least 0.5 mm greater than the diameter of the planned elastic nail [Figure 3]. Proper selection of the nail diameter was performed on the basis of the width of the affected intramedullary canal. The appropriate nail diameter was determined by measuring the diameter of the narrowest part of the medullary canal (medullary isthmus) on a radiograph and the nail diameter is about (40-60%) of the medullary isthmus. Nail contouring into was performed in a C-shaped configuration, with the tip of the curve at the apex of the fracture site. The arch of the curve of the nail should be three times the diameter of the bone into which it is to be inserted [Figure 4].
|Figure 3: The entry hole is created with a short awl 2 cm above the growth plate.|
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|Figure 4: Contouring of the flexible intramedullary nail before insertion.|
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The elastic nail was bent to achieve a three-point fixation at the fracture site. Retrograde insertion of the properly selected nail was then performed. Once the nail reached the fracture site, closed reduction was performed under C-arm control.
After proper alignment and fracture reduction, the nail was introduced into the proximal fragment. Multiple and forceful reduction attempts were avoided. Curvature of the nail facilitated some reduction and could be rotated to achieve the best alignment. The nail was driven proximally to within 1-2 cm from the proximal humeral physis. The protruding distal end of the nail was then trimmed at 0.5 cm from the bone for easy removal later on. Then, the wound was thoroughly irrigated and closed in two layers without drainage. The single nail acted as an internal splint and maintained the alignment until the fracture healed.
All the patients were then instructed to keep their arms in a functional brace as an additional external support for not more than 3 weeks [Figure 5]. During this period, the patients were advised to perform pendulum exercises. From the fourth week onwards, they were encouraged to progress from passive assisted to active exercises as tolerated.
Radiographs were obtained immediately [Figure 6], 2 weeks postoperatively to check for loss of reduction, and 4, 8, and 12 weeks postoperatively to evaluate healing [Figure 7]. The functional outcome was evaluated according to the system of Broberg and Morrey , for the evaluation of elbow function and the DASH score for the evaluation of shoulder function and disability . The functional outcome was compared with the healthy side.
|Figure 6: Immediate postoperative radiograph showing a fracture fixed by a single flexible intramedullary nail.|
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The Broberg and Morrey system for the evaluation of elbow function is a primary short-term outcome measure. This 100-point rating system is based on motion (40 points), strength (20 points), stability (5 points), and pain (35 points). The surgeon rates pain as none (35 points), mild with activity but requiring no medication (28 points), moderate with or after activity (15 points), or disabling pain that is severe at rest and requires constant medication (0 points). The motion was measured using a hand goniometer and by assessing flexion/extension of the elbow and pronation/supination of the forearm. The grip strength of the hand and stability of the elbow joint were also assessed. Categorical ratings were assigned according to the score achieved: a score of 95-100 points is rated excellent; 80-94 points as good; 60-79 points as fair; and less than 60 points as poor.
Solid union was confirmed when at least three cortices showed periosteal new bone formation on standard plain anteroposterior and lateral views, and radiological follow-up was graded according to the system proposed by Stans et al.  (grading of callus formation) [Table 1]. Although this system was at first designed for the follow-up of the diaphyseal femoral fractures, it was found to be useful and easily applicable for all diaphyseal fractures of long bones.
| Results|| |
For all the patients included, the following data were documented: time lapse from injury to surgery, operative time, hospital stay, time to bone healing, time of removal of the implant, pain, range of motion an stability of the shoulder and elbow joints, functional status, grip strength of the hand, humeral length discrepancy, whether there were any angulation and/or rotation at the fracture site, and complications. The humeral length discrepancy was measured clinically by comparing the distance from the medial epicondyle to the coracoid process, and was compared with the healthy side.
The duration from trauma to surgery ranged from 6 to 72 h. The indications for surgical stabilization included achievement of adequate alignment in cases with failed conservative measures in five fractures (loss of reduction in the early follow-up period after 3 days of using U-shaped splint) and inability to achieve adequate alignment in unstable fractures by primary closed reduction under the C-arm (nine fractures). The indications for surgery in the remaining six patients were to allow early mobility in the presence of lower extremity fractures (two cases), nursing care in associated abdominal organ injury (one case) and closed head injury (two cases), and wound care in open fractures (one case with Gustilo and Anderson grade II).
The mean operative time was 25 (range 20-45) min and the mean duration of hospital stay was 4 (range 2-15) days. The maximum hospital stay was 15 days for the complete treatment of the associated injuries.
Solid union occurred in all the cases studied, and was confirmed both clinically and radiographically within a mean of 8 (range 5-10) weeks. No blood loss was recorded with this technique.
Implant removal was performed after a mean of 5.5 (range 4-6) months as soon as bone union was achieved. Prolonged implantation of the nail was not recommended as it would be more difficult to remove. The problem was that as bone grew, the distal tip might become fully embedded in the epicondylar bone and may no longer be extracted.
Active exercises were allowed according to patients' tolerance. At the end of the minimum follow-up period of 4 months, all the patients were examined both clinically and radiographically and the functional scoring systems were completed. According to the Broberg and Morrey system, there were 18 (90%) excellent results (95-100 points), whereas in only two (10%) cases, the results were graded as good (80-94 points). Nevertheless, at the time of the final follow-up examination, all the cases studied showed excellent results (95-100 points) both clinically and radiographically.
According to the DASH scoring system, there was no difficulty or any residual symptoms related to the shoulder joints and all cases rated no disability level.
All the radiographs at the final follow-up visit were graded as grade III according to the system proposed by Stans et al.  used for grading of callus formation [Table 1].
In the current study, the complications encountered were superficial wound infections in two cases, proximal nail migration in one case, and nail entry irritation in one case. The complications recorded were managed adequately and did not affect the final clinical or radiographic end results. Complications such as deep infection, growth plate injury, neurological injury, vascular injury, refracture, implant failure, limb-length discrepancy, delayed union, nonunion, and/or malalignment were not recorded in this study. The two patients with evident preoperative radial nerve palsy improved spontaneously after surgery within 3 months and there was no need for intervention; this associated injury did not affect the final clinical or radiological outcome of the affected patients.
| Discussion|| |
The forgiving physiology of children will ensure healing, their impressive remodeling potential will at least partially compensate the deformity, and the great mobility of the shoulder joint will make any restriction of movement look trivial ,.
Probably the most significant advantage of ESIN is the avoidance of lengthy and awkward immobilization regimes without compromising the reduction. Early postoperative mobilization is the rule, and children can go back to school once they are discharged from hospital. However, the child has to undergo two open procedures under general anesthesia [1-20].
The advantages of the method outweigh the risks so clearly that it has become the recommended method of treatment for severely displaced humeral shaft fractures in children ,,,,,,,,,,,.
Titanium elastic nail fixation is an ideal procedure for the treatment of humeral shaft fractures in which stabilization is indicated as it provides stable fixation, with minimal soft tissue stripping at the fracture site, and allows early mobilization of the extremity .
In the current study, the mean follow-up period was 5.5 (range 4-6) months. The mean time to fracture union was 8 (range 5-10) weeks. The average delay from injury to surgery ranged from 6 h to 7 days, with a mean of 8 h. The mean duration of surgery was 25 (range 20-45) min. Implant removal was performed at an average of 5.8 (range 4-6) months.
In this study, two patients had a preoperative radial nerve injury. Electromyography and nerve conduction velocity were performed at 6 weeks after injury as Thomsen and Dahlin  recommended in their study. There was no denervation potential in both cases (neuropraxia) and recovered completely and spontaneously at 3 months after injury. Furlan et al.  reported in their study on one patient with preoperative radial neurapraxia involving the superficial radial nerve, which resolved after 12 weeks. Garg et al. , in their study in 2009, studied one patient with a radial neuropraxia that recovered function spontaneously within 4 months after injury and another patient with radial nerve injury who was treated with tendon transfers ~1 year after the injury to restore wrist extension. Maruthi et al. , in his study in 2013, had one patient with a preoperative radial neurapraxia that recovered function spontaneously within 2 months after injury and there was no postoperative nerve injury; he reported that the lateral dual entry point approach is better to avoid injury to the ulnar nerve.
Garg et al.  treated 13 pediatric patients with traumatic humeral shaft fractures by double titanium elastic nails. Two patients were treated with antegrade insertion of the nails and the remaining 11 patients were treated with retrograde insertion. Of the retrograde insertions, nine had medial and lateral entry portals and two had dual lateral entry portals. The authors reported that establishment of an antegrade entry required that the rotator cuff be incised in line with its fibers and retrograde entry required careful opening of the cortex to avoid iatrogenic distal humeral fracture and careful dissection of the epicondylar muscles to avoid iatrogenic ulnar nerve injury. Maruthi et al.  used two nails introduced through the distal lateral edge of the humerus above the lateral epicondyle (dual lateral entry portals) and reported that stability is enough to lead to healing without an angular or translational deformity of more than 10° within 12 weeks. In this study, the use of a single prebent nail achieved good alignment and reduction and acted as an internal splint till fracture healing occurred, and this decreased the operative time and cost, with a final favorable end result. The nail maintained the reduction and then prevented postoperative displacement, unacceptable malalignment, and rotational displacement because it was contoured into a 'C'-shaped construction, with the apex of the curve at the fracture site to allow for a three-point fixation and a stable reduction of the fracture site . A functional arm brace was used for 3 weeks in all cases. It acted as an external splint to secure the reduction that was achieved by the single nail.
The indications for surgical stabilization in Maruthi et al.'s  study included inability to maintain acceptable alignment in three (43%) patients, nursing care in one (14%) patient with closed head injury, and improved mobilization in three (43%) polytrauma patients with lower extremity fractures necessitating early upper extremity weight bearing. In this study, the indications for surgical stabilization included achievement of adequate alignment in cases with failed conservative measures in five (25%) fractures (loss of reduction in the early follow-up period after 3 days of using a U-shaped splint), inability to achieve adequate alignment in unstable fractures by primary closed reduction under the C-arm in nine (45%) fractures, nursing care in two (10%) patients with closed head injury, improved mobilization in two (10%) polytrauma patients with lower extremity fractures necessitating early upper extremity weight, nursing care in one (5%) patient with abdominal organ injury, and wound care in one (5%) patient with a second-degree open fracture.
Furlan et al.  reported that all patients achieved complete radiographic healing at a mean of 7.2 (range 5-11) weeks. Garg et al.  reported that all fractures healed in good alignment without an angular or a translational deformity more than 10° within 12 weeks. Maruthi et al.  reported that all fractures united without an angular or a translational deformity of more than 10° within 12 weeks. Sheng  reported that all fractures healed completely over a period ranging from 3 to 6 months without shortening or rotational deformity. In the current study, complete radiological union was achieved in all cases in a mean period of 9.7 weeks (ranging from 8 to 14 weeks). Two cases showed malalignment: one case showed 10° varus and the other showed rotation of the distal fragment of about 15° that was acceptable and clinically, the patient had full range of motion of the elbow and shoulder joints.
Furlan et al.  reported in their study one case with a postoperative skin infection. Gordon and Garg , in his study, reported that there were no postoperative wound infections. Maruthi et al.  reported that there was clinical evidence of a superficial infection in one patient, managed by regular dressing and antibiotics. In this study, two patients had a superficial wound infection and only one patient had proximal nail migration, and there were no delayed unions, refractures, or unacceptable malunions.
For the past 30 years, the ESIN method has become widely accepted, and is considered the standard surgical procedure for the treatment of diaphyseal fractures in children and adolescents. It has many advantages over the use of plates and external fixators, which have few indications for use in this age group. A good knowledge of the principles and strict careful application of the techniques are mandatory to obtain excellent results. This method is reliable and children benefit from its use ,.
| Conclusion|| |
The use of a single intramedullary elastic retrograde nail with the aid of a functional arm brace for fixation of the diaphyseal fractures of the humerus in children when surgical stabilization was indicated proved to be an adequate fixation technique with a very low complication rate and a favorable final clinical outcome after a short period of follow-up. It has many advantages such as a short hospital stay, no casting, small scar, early rehabilitation and joint motion, no shoulder complications, no growth plate injury recorded, and very good functional and cosmetic results. In addition, patients with concomitant lower extremity fractures can be mobilized more rapidly because of the increased ability to weight bear through the extremity. When using a single nail instead of two nails, the operative time was decreased, less radiological exposure was ensured, the cost was reduced, and yet, the final outcome was not compromised. In addition, there was no need for a second entry from the medial or the lateral side. Furthermore, no nail twisting or winding over each other occurred when using a single elastic nail.
| Acknowledgements|| |
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]